Allergic Rhinitis: Treatment and Management

Karen Rance, DNP, APRN, CPNP, AE-C
Wednesday October 21, 2015
One of the most common diagnoses in the United States, allergic rhinitis is often misdiagnosed and/or undertreated.


Allergic rhinitis (AR) is one of the most common diagnoses in the United States, affecting an estimated 10% to 30% of adults and up to 40% of children.1 Research estimates that AR is the reason for 13 million medical office visits annually,2 many of which are to retail clinics. Each year, 25% of US households have at least 1 member with AR symptoms.3 It is common for patients to have tried multiple OTC allergy medicines before they seek professional medical care for their AR symptoms. The financial and societal burdens of AR are significant and have been referred to by some as “massive.”4 Studies show AR also has a negative impact on a patient’s quality of life, affecting emotional function, activities, sleep, and comorbid conditions.5
 
In 2006, a landmark study, “Allergies in America,” surveyed 2500 adults who had been diagnosed with either AR or nonallergic rhinitis and who had taken prescription allergy medication in the previous 12 months. The survey results demonstrated the most commonly reported symptom was nasal congestion. Nearly 40% of patients said that their related discomfort was intolerable without some sort of relief measures. Survey results also demonstrated an average productivity decline of 25% among employees on days when they had significant allergy symptoms and 30% of employees losing workdays due to uncontrolled allergy symptoms in the past year.5
 
AR is often misdiagnosed and/ or undertreated.3 Patients with AR often present to medical practitioners requesting antibiotics for what they think is a sinus infection when what they need is appropriate treatment for AR. The misdiagnosis of AR contributes to and perpetuates the overuse of oral antibiotics. Retail clinic nurse practitioners (NPs) and physician assistants (PAs) are at the front line of patient care and have a great opportunity to educate patients regarding the commonality and characteristics of AR and offer an evidence-based treatment plan.
 
This article will review a case study of a patient with AR. The diagnosis and management of AR will be discussed along with evidence-based options for treatment.
 
History
Brooke is a 16-year-old girl, accompanied by her father, who presents to your clinic for the first time with the chief complaint of a flare of her allergy symptoms this fall. She states that since her school year started 2 months ago in early August, her “allergies have been terrible.” Brooke has had seasonal allergies since she was 9 years old, and her father states that they have typically controlled Brooke’s symptoms over the past several years with OTC antihistamines and OTC eye drops. He states that he typically sees a spike in Brooke’s allergy symptoms each spring when the trees start blooming, but that her symptoms are much better by July. Brooke reports having difficulty staying awake during her school day, and she is not sure if it is due to the allergy pill she takes in the morning or because her nasal congestion is keeping her awake at night. She is complaining of sneezing, an itchy nose, itchy eyes, clear runny nose, and postnasal drip. Brooke’s father states that the last time she had similar symptoms she was prescribed a 5-day course of antibiotics and wonders if she is getting more antibiotics today.
 
Brooke recently tried an OTC corticosteroid (fluticasone propionate) nasal spray after she and her father saw a poster about the medicine at her pharmacy. Typically, she only uses her nasal spray when her symptoms are “really bad,” but her current symptoms necessitated her using the nasal spray twice daily for the past 6 weeks. She states she doesn’t like nasal sprays very much because the medication “runs down” the back of her throat. She recently added a second-generation oral antihistamine to her daily medications, but her symptoms persist. She has also tried OTC allergy eye drops as needed and reports her eye symptoms have somewhat improved. When questioned, Brooke states she is adherent with her medications.

DISCUSSION QUESTION: What additional information would you want to know about Brooke’s history and current illness?

ANSWER: A patient’s medical history is critical to an accurate diagnosis. You decide that you need a more detailed medical history from Brooke and proceed to ask her additional questions that elicit the following information:
  • Review of symptoms: Brooke complains of sneezing, and itchy nose, itchy eyes, clear runny nose, and postnasal drip. She denies any discolored nasal mucus, fever, sore throat, or headaches, and does not have coughing, shortness of breath, or nocturnal cough.
  • Previous medical history: Brooke has no history of other medical problems or known drug allergies.
  • Environmental history: Brooke and her family live in the Midwest in a home surrounded by trees on 1 acre of land. She has no pets, although she wants to adopt a cat. No one smokes around her. She redecorated her bedroom last year and, at that time, got a new mattress and pillow.
  • Family history: Brooke’s mother has similar seasonal allergy symptoms that she treats with alternating OTC loratadine and cetirizine.
  • Social history: Brooke is in 11th grade and has always been an excellent student; this school year, however, she has gotten off to a rough academic start. She is in choir and on the debate team, and her nasal congestion and postnasal drip have impacted her voice and ability to sing. She has upcoming tryouts for show choir, and it is very important that she is able to sing to the best of her ability.


Current Issue

The Educated Patient

Katarzyna Lalicata, MSN, FNP-C, FNP-BC
The symptoms associated with colds, most commonly congestion, coughing, sneezing, and sore throats, are the body's response when a virus exerts its effects on the immune system. Cold symptoms peak at about 1 to 2 days and last 7 to 10 days but can last up to 3 weeks.
Kristen L. Marjama, DNP, APRN-BC, FNP
Exposure to damp and moly environments may also result in a variety of other health issues.
Bethany Rettberg, NPC
An accurate medical history and a physical exam are critical to rule out more serious conditions.
Bethany Rettberg, NPC
Practitioners should get a detailed medical history and conduct a thorough physical to treat sinus infections.
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